The 7-day-old neonate born at 32-weeks’ gestation has an axillary temperature of 38.9°C. The nurse notes the infant is lethargic, with pale extremities and flash central capillary refill. Which nursing action is appropriate?

Advocate for a sepsis evaluation. The premature neonate with an elevated temperature, lethargy, pale extremities, and flash central capillary refill is likely septic; therefore, a sepsis evaluation should be performed. If the patient was well-appearing with an elevated temperature, then the appropriate action would be to decrease ambient temperature and reassess in one hour. The patient’s symptoms without the elevated temperature might indicate the need for an echocardiogram to rule out cardiac defects, but the clinical picture indicates sepsis.

The 7-day-old neonate born at 32-weeks’ gestation has an ax...

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Health Promotion and Maintenance
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Category: Health Promotion and Maintenance
Difficulty: 8

Topics: Cardiovascular Neonatal Care Respiratory Immunity Infection Inflammation

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